Along the continuum from reduction to mastectomy: An algorithmic approach to the gender diverse top surgery patient

Abstract

The number of patients presenting for gender affirming surgery (GAS) whose gender identity is not defined within the cis or transgender binary has increased steadily. 1 Koehler A. Eyssel J. Nieder T.O. Genders and Individual Treatment Progress in (Non-)Binary Trans Individuals. J Sex Med. 2018; 15 (Jan): 102-113https://doi.org/10.1016/j.jsxm.2017.11.007 Crossref PubMed Scopus (61) Google Scholar , 2 Cuccolo N.G. Kang C.O. Boskey E.R. Ibrahim A.M.S. Blankensteijn L.L. Taghinia A. Lee B.T. Lin S.J. Ganor O. Masculinizing Chest Reconstruction in Transgender and Nonbinary Individuals: An Analysis of Epidemiology, Surgical Technique, and Postoperative Outcomes. Aesthetic Plast Surg. 2019; 43 (Dec): 1575-1585https://doi.org/10.1007/s00266-019-01479-2 Crossref PubMed Scopus (19) Google Scholar , 3 McTernan M. Yokoo K. Tong W. A Comparison of Gender-Affirming Chest Surgery in Nonbinary Versus Transmasculine Patients. Ann Plast Surg. 2020; 84 (May): S323-S328https://doi.org/10.1097/SAP.0000000000002254 Crossref PubMed Scopus (5) Google Scholar Compared to trans-masculine patients, gender diverse patients identifying as nonbinary, agendered or other, are more likely to request a type of procedure that may be between a full chest masculinization and a standard breast reduction. 3 McTernan M. Yokoo K. Tong W. A Comparison of Gender-Affirming Chest Surgery in Nonbinary Versus Transmasculine Patients. Ann Plast Surg. 2020; 84 (May): S323-S328https://doi.org/10.1097/SAP.0000000000002254 Crossref PubMed Scopus (5) Google Scholar , 4 Friedman R. Garvey S.R. Nanda A. Boustany A.N. Tobias A.M. Cauley R.P. Breast reduction as gender-affirming chest surgery in non-binary patients: Addressing the needs of a growing population. J Plast Reconstr Aesthet Surg. 2022; 76 (Dec 1): 12-14https://doi.org/10.1016/j.bjps.2022.11.056 Abstract Full Text Full Text PDF Scopus (0) Google Scholar The aesthetic goals for our gender diverse patients seeking breast reductions may also differ from those of cis-gendered individuals. 3 McTernan M. Yokoo K. Tong W. A Comparison of Gender-Affirming Chest Surgery in Nonbinary Versus Transmasculine Patients. Ann Plast Surg. 2020; 84 (May): S323-S328https://doi.org/10.1097/SAP.0000000000002254 Crossref PubMed Scopus (5) Google Scholar Furthermore, a breast reduction can sometimes be a transitional procedure for gender diverse patients, followed by additional GAS in the future; Of the gender diverse patients who underwent breast reduction at our institution, one quarter eventually sought further masculinizing chest surgery. Despite these complexities, there is no guidance in the literature on how to treat the unique and increasingly common cohort of patients who do not identify within the cis or transgender binary. 3 McTernan M. Yokoo K. Tong W. A Comparison of Gender-Affirming Chest Surgery in Nonbinary Versus Transmasculine Patients. Ann Plast Surg. 2020; 84 (May): S323-S328https://doi.org/10.1097/SAP.0000000000002254 Crossref PubMed Scopus (5) Google Scholar For gender diverse patients seeking a breast reduction or another chest procedure as GAS, it is vital to ensure the surgical technique (1) aligns with the patient’s aesthetic goals and (2) will have a negligible impact on the outcome of possible future GAS.4.5 To ensure these goals are met, we have devised a novel institutional algorithm and surgical strategy for the gender diverse cohort.